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Double Slide Viewing as a Cytology Quality Improvement Initiative

Stephen S. Raab MD, Chad H. Stone MD, Chris S. Jensen MD, Richard J. Zarbo MD, DMD, Frederick A. Meier MD, Dana M. Grzybick MD, PhD, Colleen M. Vrbin, N. Paul Ohori MD, Laila Dahmoush MD
DOI: http://dx.doi.org/10.1309/TKNM9GRGPL2JT95Y 526-533 First published online: 1 April 2006


Few studies have measured the effect of pre–sign out double viewing of cytology cases as a means to decrease error. Three Agency for Healthcare Research and Quality–funded project sites performed pre–sign out double viewing of 431 pulmonary cytology cases. Two-step or more differences in diagnosis were arbitrated as interpretive errors, and the effect of double viewing was measured by comparing the frequency of cytologic-histologic correlation–detected errors in the previous 2 years with the double-viewing period. The number of interpretive errors detected by double viewing for the 3 institutions was 2.7%, 0%, and 1.9%, respectively. Double viewing did not lower the frequency of cytologic-histologic correlation false-negative errors. We conclude that double viewing detects errors in up to 1 of every 37 cases and that biases in the double-viewing process limit error detection.

Key Words:
  • Patient safety
  • Redundancy
  • Pathology
  • Error